Post-operative small bowel obstruction: spiral computed tomography

INTRODUCTION: The aim of this study was to evaluate prospectively the impact of the routine use of abdominal spiral computed tomography (SCT) in patients with postoperative small bowel obstruction (SBO) for whom initial conservative treatment was proposed. PATIENTS AND METHODS: We have compared the management of SBO in patients with clinical stable condition in two successive periods : from 1989 to 1998, 127 patients (preSCT group) for whom management was based on standard clinical-biological-radiological assessment (CBRA) et from 1999 to 2000, 30 patients (SCT group) for whom management included SCT. The decision of surgical team was correlated with the type of small bowel obstruction at laparotomy : closed-loop obstruction without intestinal necrosis (true-positive), intestinal necrosis as a consequence of delayed diagnosis defined as false-negative, diffuse adhesion defined as false-positive et patient non operated defined as true-negative. RESULTS: Among the 127 patients from the preSCT group, 87 were treated conservatively and 40 were operated : SBO with closed-loop obstruction without intestinal necrosis (n = 29,72%), SBO with diffuse adhesion (n = 4, 10%) and SBO with intestinal necrosis (n = 7, 17%). Among the 30 patients from the SCT group, 16 were treated conservatively and 14 were operated: SBO with closed-loop obstruction without intestinal necrosis (n = 8, 57%), SBO with diffuse adhesion (n = 6,43%) and SBO with intestinal necrosis (n = 0,0%; NS). Both groups were similar for rates of patients with SBO with or without necrosis and rate of patients treated conservatively (NS). In SCT group, there was significantly more patients operated for diffuse adhesions (p < 0,01). Negative predictive value of CBRA + TDM was significantly higher than those of CBRA alone (p = 0,041). CONCLUSION: Due to a very high sensibility, TDM increase probably the rate of early laparotomies, maybe unnecessary, in patients without any sign of SBO due to closed-loop obstruction. Thus, systematic use of TDM in patients with clinical suspicion of SBO remains to be evaluated.     

Small bowel metastases from head and neck cancers

AIM OF THE STUDY: Small bowel metastases represent less than 10% of malignant tumours of the small bowel. Among primitive cancers with small bowel metastases, head and neck cancers are exceptional. The aim of the study was to evaluate clinical and evolutive characteristics of patients with small bowel metastases from head and neck cancers. PATIENTS AND METHODS: Analyse of a reported case and bibliographic study by asking the Medline database and gathering anamnestic, clinical and evolutive data from observations of small bowel metastases from head and neck cancers. RESULTS: We report the case of a 63 years-old male patient with a small bowel metastasis from a head and neck cancer. Nine other observations have been published in the international literature. Analysis of this 10 patient-series shows that small bowel metastases of head and neck cancers occur rather in old male patients (mean age: 71 years). They are usually discovered after primitive cancer diagnosis, always because of occlusive, perforative or bleeding complications. Jejunal metastases are rather complicated by perforation whereas ileal ones rather induce occlusion or digestive bleeding. Discovering a small bowel metastasis in the context of head and neck cancer is highly indicative of a poor prognosis. In these 10 patients, deaths occurred within the 8 months following the diagnosis, because of postoperative complication or neoplastic evolution. CONCLUSIONS: Small bowel metastases from head and neck cancers usually occur as emergent complications. They are indicative of an advanced disease and the prognosis is extremely poor. The aim of the management is to afford the best quality of life as possible.     

Small bowel obstruction by an anomalous congenital band

We report a case of a 3-year-old boy who presented with symptoms and signs of intestinal obstruction. The patient reported no previous history of abdominal surgery or trauma while clinical and radiographic examinations were not diagnostic. An open laparotomy was subsequently performed and the intraoperative findings were consistent with a congenital band extending from the antimesenteric wall of the jejunum to the root of mesentery. The band was ligated and divided with an uneventful postoperative course. Congenital bands are extremely rare. Their exact incidence is still unknown. This case, therefore, represents an unusual surgical problem in a child in which the diagnosis was clinically unexpected.     

Small bowel obstruction caused by congenital mesocolic hernia: case report

Transmesocolic hernias are extremely rare. Their exact incidence is still unknown. A strangulated hernia through a mesocolic opening is a rare operative finding. Preoperative diagnosis still is difficult in spite of imaging techniques currently available. This is the case of a 4-month-old boy with transmesocolic internal hernia and coincident intestinal malrotation and volvulus of small bowel.     

Anaesthesia for non cardiac surgery in patients with grown-up congenital heart disease

Objectives

To be aware of the different grown-up congenital heart diseases. To know their physiopathology, adverse events and the way to manage patients presenting with these pathologies in the anaesthesia for non cardiac surgery setting.

Data source

References were obtained from Pubmed data bank (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi) using the following keywords: congenital heart disease, congenital cardiac disease, atrial septal defect, ventricular septal defect, Eisenmenger syndrom, cavopulmonary shunt, tetralogy of fallot, endocarditis.

Data synthesis

Nowadays, there are equal numbers of adults and children with congenital heart disease. These patients can be divided into three different groups: patients with corrective surgery, patients with palliative surgery, and patients with uncorrected congenital heart disease. In the non cardiac surgery setting, anaesthetists will have to cope with increasing number of adult patients with grown-up congenital heart disease. Because of the complexity and the severity of these lesions it is highly recommended to contact referral centers for the management of these patients. The most frequent complications in this setting are: arrhythmia, hypoxia, cardiac failure, and paradoxal air embolism. Anaesthesia management in this setting requires perfect comprehension of the physiology and anatomy. For the most severe pathologies, it is recommended to refer these patients to referral centres.     

A case report of small bowel obstruction secondary to congenital peritoneal band in adult

IntroductionSmall bowel obstruction (SBO) is common in adult surgical procedures, mainly due to postoperative adhesions. Acute SBO in adults without history of abdominal surgery, trauma or clinical hernia is less common and has various etiologies. Congenital band is an extremely rare cause.Presentation of caseA 56-year-old man was admitted to our hospital with a two-day history of abdominal pain and bilious vomiting. He had no history of abdominal surgery or any other medical problems. A contrast-enhanced CT of the abdomen showed a distention of small bowel loops with transition point in the right hypochondrium. Distended loops of small bowel were located in the left side of the abdomen, whereas collapsed loops was located in the right side. The normal bowel wall enhancement was preserved. After initial treatment with intravenous fluid and nasogastric suction, he was operated. At laparoscopy a band obstructing the ileum was clearly observed. This anomalous band extending from gallbladder to transverse mesocolon caused a small window leading to internal herniation of the small bowel and obstruction. The band was coagulated and divided. Postoperative outcome was uneventful and the patient was discharged on the second postoperative day. There was no recurrence of symptoms on subsequent follow-up.DiscussionCongenital peritoneal bands are not frequently encountered in surgical practice and these bands are often difficult to classify and define. Diagnosis of acute intestinal obstruction due to CPB must be included in the differential diagnosis in any patient with no history of abdominal surgery, trauma, clinical hernia, inflammatory bowel disease or peritoneal tuberculosis.ConclusionDespite technological advances in radiology preoperative diagnosis remains difficult, however the diagnosis of SBO due to CPB must be considered in any patient with no history of abdominal surgery, Trauma or clinical hernia consulting for occlusive syndrome. The laparoscopic approach should be intended initially for its feasibility and benefits.     

Small bowel obstruction caused by a medication bezoar: Report of a case

We report herein the rare case of a 26-year-old woman who developed a small-bowel obstruction caused by a medication bezoar or enterolith, following the long-term ingestion of magnesium oxide cathartics for constipation. Medication bezoars resulting from laxatives or cathartics have rarely been reported and we were only able to find two other such cases in the literature.     

Small bowel obstruction caused by anisakiasis of the small intestine: report of a case

Enteric anisakiasis is a relatively rare disease that is difficult to diagnose preoperatively. We report a case of small bowel obstruction caused by enteric anisakiasis in a 59-year-old Japanese man who presented with abdominal pain a few hours after eating sliced, raw fish. Because of signs of an intestinal obstruction, a laparotomy was performed. Focal thickening and stenosis of the ileocecal region were seen about 100 cm from the end of the ileum and the lesion was excised. We found a moving anisakis thrusting its head into the mucosa of the excised small intestine. Histopathological examination revealed the infiltration of eosinophils in all layers of the intestinal wall and severe edema. Enteric anisakiasis is very rare, and its diagnosis is usually only made after laparotomy. Nevertheless, when signs of acute abdomen develop after the ingestion of raw fish, such as sushi or sashimi, the possibility of enteric anisakiasis should be borne in mind. Received: February 25, 2002 / Accepted: July 2, 2002 Reprint requests to: T. Sasaki     

Small bowel obstruction in the virgin abdomen: the need for a mandatory laparotomy explored

Background

A laparotomy is still considered mandatory for patients without previous abdominal surgery presenting with a small bowel obstruction (SBO) because of a perceived high incidence of underlying lesions. However, there is no evidence in literature to support this assumption. We analyzed the etiology of SBO in this subgroup of patients to establish the need for a mandatory laparotomy.

Methods

A retrospective analysis was conducted over a 5-year period. Basic demographics, radiology results, operative findings, and outpatient investigations were analyzed.

Results

Of 689 patients presenting with an SBO, a total of 62 patients, 9.0%, had a virgin abdomen. A known underlying disease (inflammatory bowel disease, malignancy) was the cause in 13 patients. The remaining 49 patients had adhesions in 75.5% and a newly diagnosed malignancy in 10.2% as a cause.

Conclusions

Adhesions are by far the most likely cause of SBO in patients without previous abdominal surgery followed by a small number of newly diagnosed malignancies. Both prevalences are in equal proportion to patients with previous abdominal surgery. A trial of nonoperative management may therefore be justified.     

Small bowel obstruction in pregnancy is a complex surgical problem with a high risk of fetal loss

IntroductionSmall bowel obstruction (SBO) in pregnancy is rare and is most commonly caused by adhesions from previous abdominal surgery. Previous literature reviews have emphasised the need for prompt laparotomy in all cases of SBO because of the significant risks of fetal loss and maternal mortality. We undertook a review of the contemporary literature to determine the optimum management strategy for SBO in pregnancy.MethodsThe MEDLINE® and PubMed databases were searched for cases of SBO in pregnancy between 1992 and 2014. Two cases from our own institution were also reviewed.ResultsForty-six cases of SBO in pregnancy were identified, with adhesions being the most common aetiology (50%). The overall risk of fetal loss was 17% and the maternal mortality rate was 2%. In cases of adhesional SBO, 91% of cases were managed surgically, with 14% fetal loss. Two cases (9%) were managed conservatively with no complications. Magnetic resonance imaging (MRI) was used to diagnose SBO in 11% of cases.ConclusionsBased on our experience and the contemporary literature, we recommend that urgent MRI of the abdomen should be undertaken to diagnose the aetiology of SBO in pregnancy. In cases of adhesional SBO, conservative treatment may be safely commenced, with a low threshold for laparotomy. In other causes, such as volvulus or internal hernia, laparotomy remains the treatment of choice.     

Octreotide improved the quality of life in a child with malignant bowel obstruction caused by peritoneal dissemination of colon cancer

This is a first pediatric case about the efficacy of octreotide for improving symptoms of malignant bowel obstruction. A 12-year-old boy was referred to our hospital for treatment of transverse colon cancer with peritoneal dissemination. A transverse colectomy was undertaken with postoperative adjuvant chemotherapy. Seven months later, severe abdominal symptoms occurred caused by incomplete bowel obstruction owing to tumor progression. The patient's quality of life decreased with a resultant disturbed mental condition. His parents sought to stop chemotherapy and for him to receive palliative care at home. We suggested nasogastric tube placement, but this was rejected. After obtaining informed consent, octreotide was administered intravenously. After 1 week, abdominal symptoms improved and the boy's complaints stopped. He had a good appetite and was able to eat small amounts of food. He was able to spend his final 2 months at home without nausea and in his family surroundings.